minimal intervention dentistry for managing carious

Vol.:(0123456789)1 3

European Archives of Paediatric Dentistry https://doi.org/10.1007/s40368-021-00675-6

SYSTEMATIC REVIEW

Minimal intervention dentistry for managing carious lesions into dentine in primary teeth: an umbrella review

A. BaniHani1 · R. M. Santamaría2 · S. Hu3 · M. Maden4 · S. Albadri5

Received: 25 July 2021 / Accepted: 8 October 2021 © The Author(s) 2021

AbstractPurpose This umbrella review systematically appraised published systematic reviews on Minimal Intervention Dentistry interventions carried out to manage dentine carious primary teeth to determine how best to translate the available evidence into practice, and to provide recommendations for what requires further research.Method An experienced information specialist searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the NIHR Jour-nals Library. In addition, the PROSPERO database was searched to identify forthcoming systematic reviews. Searches were built around the following four concepts: primary teeth AND caries/carious lesion AND Minimal Intervention Dentistry AND systematic review/meta-analysis. Searches were restricted to English language, systematic reviews with/without meta-analyses published between January 2000 and August 2020. Two reviewers independently screened all titles and abstracts. Interventions included involved no dentine carious tissue removal (fissure sealants, resin infiltration, topical application of 38% Silver Diamine Fluoride, and Hall Technique), non-restorative caries control, and selective removal of carious tissue involving both stepwise excavation and atraumatic restorative treatment. Systematic reviews were selected, data extracted, and risk of bias assessed using ROBIS by two independent reviewers. Studies overlap was calculated using corrected covered area.Results Eighteen systematic reviews were included in total; 8 assessed the caries arresting effects of 38% Silver Demine Fluoride (SDF), 1 on the Hall Technique (HT), 1 on selective removal of carious tissue, and eight investigated interventions using atraumatic restorative treatment (ART). Included systematic reviews were published between 2006 and 2020, covering a defined time frame of included randomised controlled trials ranging from 1969 to 2018. Systematic reviews assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded due to pooled data reporting on caries arrest in both enamel and outer third of dentine with the majority of these carious lesions being limited to enamel. Therefore, fissure sealants and resin infiltration are not recommended for the management of dentinal caries lesions in primary teeth. Topical application of 38% SDF showed a significant caries arrest effect in primary teeth (p < 0.05), and its success rate in arresting dental caries increased when it was applied twice (range between 53 and 91%) rather than once a year (range between 31 and 79%). Data on HT were limited and revealed that preformed metal crowns placed using the HT were likely to reduce discomfort at time of treatment, the risk of major failure (pulp treatment or extraction needed) and pain compared to conventional restorations. Selective removal of carious tissue particularly in deep carious lesions has signifi-cantly reduced the risk of pulp exposure (77% and 69% risk reduction with one-step selective caries removal and stepwise excavation, respectively). ART showed higher success rate when placed in single surface compared to multi-surface cavities (86% and 48.7–88%, respectively, over 3 years follow-up).Conclusion Minimal Intervention Dentistry techniques, namely 38% SDF, HT, selective removal of carious tissue, and ART for single surface cavity, appear to be effective in arresting the progress of dentinal caries in primary teeth when compared to no treatment, or conventional restorations. There is clear need to increase the emphasis on considering these techniques for managing carious primary teeth as a mainstream option rather than a compromise option in circumstances where the conventional approach is not possible due to cooperation or cost.

Keywords Minimal intervention dentistry · Dentine caries · Primary teeth · Non-operative · Selective caries removal · Sealing dental caries

Extended author information available on the last page of the article

http://orcid.org/0000-0002-7733-272X

http://crossmark.crossref.org/dialog/?doi=10.1007/s40368-021-00675-6&domain=pdf

European Archives of Paediatric Dentistry

1 3

Introduction

Dental caries is well recognised as a controllable chronic disease that can be identified, diagnosed, and managed using biological approaches. The concept of MID for man-aging carious lesions has developed based on biological concepts and evidence-based outcomes of novel and exist-ing caries control interventions which focuses on detecting carious lesions as early as possible, remineralising enamel and dentine using optimal caries control measures, and on other occasions, the use of minimal invasive opera-tive interventions, and the concept of repair rather than replacement of restorations to arrest the progression of carious lesions (Ericson et al. 2003; Frencken et al. 2012; Dorri et al. 2015; Schwendicke et al. 2016). These con-cepts cover a wide number of procedures with the aim to manage carious lesions preserving as much of the tooth structure as possible.

The demineralisation process leading to dental caries can be controlled generally by reducing the intake and fre-quency of sugar as well as removing the dental biofilm by tooth-brushing and using a fluoride-containing toothpaste (Kidd 2011; Kidd and Fejerskov 2013). Methods to control enamel carious lesions include the use of additional fluo-ride (e.g. gel, varnish), pits and fissures sealants and resin infiltration. With respect to carious lesions into dentine, these measures are often no longer sufficient, and further minimally invasive (operative) interventions should be considered. Specifically for primary teeth, minimal inter-vention caries control strategies include a wide range of approaches, including those where carious tissue removal is not involved, such as non-restorative cavity control (NRCC) (Gruythuysen et al. 2011; Santamaria et al. 2018), sealing the carious lesion with fissure sealants (FS) and resin infiltration (Borges et al. 2012; Hesse et al. 2014; Splieth et al. 2020b; Paris et al. 2020), topical application of silver diamine fluoride (38% SDF mainly) (Chibinski et al. 2017; Richards 2017), and the Hall Technique (HT) (Innes et al. 2017; BaniHani et al. 2018; Santamaria and Innes 2018).

On a wider scope, management techniques include those in which dentine carious tissue is selectively removed to soft or firm dentine at one visit including atraumatic restorative treatment (ART) or the stepwise removal, which involves two-step carious tissue removal, both of them to avoid pulp exposure (Ricketts et al. 2013; Bjorndal 2018).

Previously, a surgical approach using a conventional rotary carious tissue removal method was used for tooth and cavity preparation focused on preparing appropriate space to place particular restorative materials. When man-aging carious primary teeth, the surgical method is less

preferred as it removes extensive tooth structure where the tooth morphology already presents the challenges of thin enamel and dentine and relatively large pulp chambers. Furthermore, the majority of the techniques using surgical approach require the use of local anaesthesia, rubber dam and produces noise, and consequently discomfort, and fear among children in particular (Frencken et al. 2012).

In the last few decades, there has been a debate among researchers and clinicians about the advantages and disad-vantages of MID over the surgical conventional approach for treating asymptomatic primary carious teeth, and the ques-tion of whether MID methods should be considered as stand-ard techniques for management of these teeth. Nonetheless, the decision around when to use which management method should follow more recent biological evidence-based caries management concepts, which emphasises on preserving as much tooth structure as feasible and maintaining teeth func-tional for as long as possible, in case of primary teeth until these exfoliate naturally. In addition, caries management approaches in paediatric dentistry should be cost-effective as well as acceptable to carers and patients while causing the least possible discomfort to the child. There is evidence that MID methods used for children as caries management option are cost-effective (BaniHani et al. 2019) and have positive patients reported outcomes in terms of child’s pain perception, and technique acceptability by children and car-ers (Crystal et al. 2017; BaniHani et al. 2019; El-Yousfi et al. 2020; Santamaría et al. 2020).

The number of clinical studies and reviews evaluating the effectiveness of MID methods for caries management in children has significantly increased in recent years. Many of them have focused on the evaluation of success and fail-ure of the overall treatment of specific material/treatment methods rather than the overall concept of MID. Using an umbrella review design, this study aimed to obtain a compre-hensive overview of published evidence on MID interven-tions carried out to manage dentinal caries in primary teeth to determine how best to translate the available evidence into practice, and to provide recommendations for what requires further research.

Methods

The aim of this umbrella review was to appraise and summarise the available evidence on the outcomes of MID interventions in the management of dentine caries, ICDAS 4 and 5, in primary teeth. This study followed the Cochrane methodology (Version 6) (Higgins et al. 2020) and the research topic was registered in PROSPERO No. (CRD42020202434).

This umbrella review asked the following PICO questions:


1 3

1. Do patients with dentine carious lesions, ICDAS 4 and 5, in primary teeth that are managed with different types of MID compared with conventional restoration approach, placebo and no treatment have different outcomes, in terms of treatment success and failure?

2. Do the following factors (presence of preoperative radio-graph, depth of the dentine carious lesion, surface(s) affected (single-or multi-surface lesions), extent of carious removal, type of tooth (incisor/molar), mate-rial used for restoration, and method of caries removal significantly impact the clinical effectiveness (clinical outcomes) of MID?

Inclusion criteria

• Participants: Children in their primary dentition with an untreated

carious lesion(s) extending into dentine, ICDAS 4 and 5 detected clinically and/or radiographically, in primary teeth that required intervention to limit caries progres-sion using MID without the use of local anaesthetic. Only teeth without pre-existing restorations will be considered to exclude the possibility of the dental pulp being com-promised by previous treatment.

• Intervention: Recent consensus statements established recommenda-

tions on how and when to intervene in when managing carious lesions based on the concept of MID to assist clinical decision-making (Schwendicke et al. 2019). It was agreed that lesion activity, cavitation and cleansa-bility should be considered as the main factors to decide on the management options to be used. Considering this, inactive carious lesions do not frequently involve any treatment in terms of lesion control, however, active carious lesions do. In terms of lesions cavitation, non-cavitated carious lesions and also cavitated carious lesions, which are cleansable should be managed non-or micro-invasively. Cavitated carious lesions, which are not cleansable usually require restorative management. Addi-tional restorative treatment might be indicated in cases when form, function and aesthetics of the tooth needed to be restored.

In this Umbrella review, the following interventions were included:

o No dentine carious tissue removal: this included fis-sure sealants, resin infiltration, topical application of 38% SDF, and HT. Resin infiltration involves the use of a resin to seal carious lesions, preventing acid penetration and stop progression of caries. Whereas SDF (38%) is a topical colourless solution of silver, and fluoride (44,800 ppm) aims to arrest carious lesions. In HT, a preformed metal crown (PMC) is

cemented over the primary molar to seal dentine carious lesions.

o NRCC: in this treatment group, cavitated dentine carious lesions are transformed to cleansable forms that can be cleaned by the patient or carer with a toothbrush using fluoridated toothpaste.

o Selective removal of carious tissue including both to soft and firm dentine: this included selective removal of carious tissue until either soft or firm dentine is reached to avoid pulp exposure. Periphery of the cavity is cleaned to hard (sound) dentine. This intervention arm also included stepwise removal and ART.

Stepwise removal is a technique that involves 2-step caries removal, where selective removal to soft dentine pulpally is conducted in the first step and the cavity is provisionally restored, followed 6–12 months later by selective removal to firm den-tine pulpally and placement of definite restoration. In ART, carious tissue is removed pulpally using hand instruments only and cavity is restored with high viscosity glass ionomer cement (HVGIC).

• Comparator(s)/control: Conventional restoration approach including non-

selective caries removal to hard dentine (formally known as complete caries removal), vital pulp therapy, placebo and no treatment.

Treatment outcomes

The main outcome of this umbrella review was “successful” measured by:

• Clinically tooth remained symptom-free in place through-out the follow-up period with lack of pain, swell-ing, abscess, fistula, and mobility.

• Radiographically lack of bifurcation involvement, peri-apical radiolucency and pathological root resorption.

• Caries was arrested with no further progression clinically and radiographically.

• Restoration appeared satisfactory with no further inter-vention required.

Secondary outcomes were:

• Treatment failure were categorised into minor and major failure;

o Minor failure: if the initial treatment provided has failed, where the tooth remained restorable in place and did not result in the tooth being extracted. This was measured by development of secondary caries,


1 3

caries progression, restoration loss, and occurrence of reversible pulpitis (clinically pain on eating/drinking lasts for a few seconds) which could be managed by repair or replacement of the restoration.

o Major failure: if the initial treatment provided has failed, where the tooth inevitably had to be extracted or a pulp treatment had to be performed. This was measured by pulpal exposure during treatment, clin-ical and radiographic signs or symptoms of irrevers-ible pulpal damage such as dental abscess, fistula, spontaneous pain, periapical radiolucency, bifurca-tion involvement, or if the tooth is broken down and unrestorable.

• Time to treatment/restoration failure/retreatment meas-ured by months.

• Discomfort associated with the procedure reported at time of the dental appointment or within 24 h of treat-ment.

• Patient/carer perceptions and acceptance of treatment measured quantitatively or qualitatively.

• Oral health-related quality of life measured quantitatively or qualitatively.

• Adverse events and side effects.

We included systematic reviews (SRs) with and without meta-analyses. We excluded studies reviews in which car-ies removal was assisted by chemomechanical agents, or procedures were local anaesthesia were used to perform the treatment. We also excluded reviews concentrating on prevention or management of enamel lesions. In addition, reviews presenting pooled data reporting randomised clini-cal trials (RCTs) and SRs were excluded. For reviews inves-tigating other interventions alongside MID, only MID data were considered.

Search strategy

An experienced information specialist searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Epis-temonikos, Joanna Briggs Institute Database of System-atic Reviews and Implementation Reports and The NIHR Journals Library. In addition, the PROSPERO database was searched to identify forthcoming SRs.

Searches were built around the following four concepts: primary teeth AND caries/carious lesion AND Minimal Intervention Dentistry AND systematic review/meta-analy-sis. Searches were restricted to English language SRs and/or meta-analyses published between January 2000 and August 2020. The full search strategies can be found in the Supple-mentary File (File 1). Reference lists of the included studies were also screened. Search results were downloaded into a

reference management software (Endnote, Version 9) and duplicates removed.

Reviews selection process

Two reviewers (ABH, SH) independently screened all titles and abstracts. Following this, the same investigators screened the full text of studies assessed as being relevant or potentially relevant from the title and abstract screen. Two different reviewers resolved disagreements (RS, SA). Data from all included studies were extracted and assessed using designed data extraction forms.

For each review, the following data were recorded sys-tematically: publication details (authors, year of publica-tion, country of origin, and source of study funding), sam-ple characteristics (participants age, inclusion and exclusion criteria), review methodology (search strategy, PICO items, objectives, number of included studies, study design, sam-ple size, risk of bias assessment tool used, and method of grading the quality of evidence), teeth and any intervention carried out (tooth type, caries depth, surface(s) affected, presence of preoperative radiographs, pulpal condition, intervention and control used including type and method of restoration, extent of carious removal, method of car-ies removal and follow-up duration), outcome information including methods of assessment and information regarding risk of bias.

Risk of bias assessment

Risk of bias was conducted independently by two reviewers using the Risk of Bias in Systematic reviews (ROBIS) tool to assess each SRs across three areas:

• Relevance of the review• Identification of concerns within the SR process under

four domains: study eligibility criteria, identification and selection of studies, data collection and study appraisal, and synthesis and findings.

• Judging risk of bias (low, high or unclear risk of bias score). Scoring discrepancies was resolved through dis-cussion until consensus was reached.

Data synthesis and analysis

The effect estimates (95% confidence intervals), and meas-ures of heterogeneity was analysed for every review. Treat-ment outcomes (success, minor and major failures) were summarized narratively through tables and synthesis of similar outcome measures were carried out to compare these across comparator interventions.

To determine the overlap in studies across the SRs, cita-tion matrices were generated, and “Corrected Covered


1 3

Areas” (CCAs) were calculated as follows: CCA = 0–5; slight, 6–10; moderate, 11–15; high, and > 15; very high overlap.

SRs of different types of MID were analysed separately because of the different treatment techniques used in the MID; however, similar populations, interventions, or out-come measures were grouped in this umbrella review.

Results

Selection of studies

The initial search in databases and other sources resulted in 252 records, of which 177 remained after duplicates were removed, and four additional publications added from screening bibliographies resulting in 181 potentially eligible reviews. 162 papers were excluded after title and abstract screening, which left 19 publications eligible for full-text review. One SR was excluded following full text review and 18 SRs, 5 without meta-analysis and 13 with meta-analysis were included, reporting on 95 studies in total. Figure 1 shows the search and assessment process flowchart of the literature search.

Characteristic of the SRs

From the 18 included SRs, 8 assessed the caries arresting effects of 38% SDF on dentine carious lesions (Duangthip et al. 2015, 2016; Gao et al. 2016; Chibinski et al. 2017; Contreras et al. 2017; Tolba et al. 2019; Jabin et al. 2020), 1 on the HT (Innes et al. 2015), 8 investigated interven-tions using ART (van’t Hof et al. 2006; Mickenautsch and Yengopal 2012; Raggio et al. 2013; Dorri et al. 2017; Tedesco et al. 2017; de Amorim et al. 2018; Tedesco et al. 2018; Ortiz-Ruiz et al. 2020), and 1 SR assessed selective caries removal technique (Ricketts et al. 2013). Included SRs were published between 2006 and 2020, covering a defined time frame of included RCTs ranging from 1969 to 2018.

Ten systematic reviews used Cochrane risk of bias assessment tool (Ricketts et al. 2013; Duangthip et al. 2015; Innes et al. 2015; Duangthip et al. 2016; Chibinski et al. 2017; Contreras et al. 2017; Dorri et al. 2017; Trieu et al. 2019; de Amorim et al. 2018; Tedesco et al. 2017), four used the Cochrane collaboration common scheme for bias (Mickenautsch and Yengopal 2012; Gao et al. 2016; Tedesco et al. 2018; Tolba et al. 2019), and two used other tools for assessment (Raggio et al. 2013; Jabin et al. 2020). However, two systematic reviews did not use

any well-defined assessment tool (van’t Hof et al. 2006; Ortiz-Ruiz et al. 2020) (Table 1).

Table 2 shows the main characteristics of the included SRs according to the considered technique.

No dentine carious tissue removal

Silver diamine fluoride (38%) for managing dentine carious lesions

The eight included SRs summarised data from 33 RCT and control clinical trials (CCT). Three SRs conducted meta-analysis to synthesise the findings (Gao et al. 2016; Chibin-ski et al. 2017; Trieu et al. 2019), and five did not include a meta-analysis (Duangthip et al. 2015, 2016; Contreras et al. 2017; Tolba et al. 2019; Jabin et al. 2020). Main outcome measure assessed in these SRs was caries arrest.

There was weak overlap between the reviews using CCA (Table 3). However, when looking into more details three reviews only included primary studies that already have been analysed in previous reviews (Duangthip et al. 2015, 2016; Contreras et al. 2017).

One SR included coronal caries in primary upper anterior teeth only (Tolba et al. 2019), another one included cari-ous primary anterior teeth and primary molars (Duangthip et al. 2016), and five SRs included data on primary teeth, however, the type of teeth (anterior or molar) was not speci-fied (Duangthip et al. 2015; Gao et al. 2016; Chibinski et al. 2017; Contreras et al. 2017; Trieu et al. 2019; Jabin et al. 2020). In addition, none of the included SRs reported on the depth of caries or the number of tooth surfaces affected included apart from Jabin et al (2020) study which stated the 38% SDF was applied on single and multi-surfaces carious lesions. Age of children in these studies ranged between 2 and 15 years, however, one SR did not state the age range (Gao et al. 2016). Follow-up period ranged between 6 and 48 months.

The SRs included studies comparing 38% SDF to no treatment, placebo or other interventions including other SDF concentrations (12%), GIC restoration, sealants, ART or 5% NaF fluoride varnish application.

Results from included SRs showed that 38% SDF has statistically significant caries arrest effect in children and that its application is more effective than other preventive management strategies including 5% NaF fluoride varnish and sealing with GIC for arresting dentinal caries in the pri-mary dentition (p < 0.5).

Caries arrest rate after single application of 38% SDF ranged between 31 and 79%, whereas biannual applica-tion has significantly increased the carries arrest rate to 53 and 91%. In addition, the mean number of arrested caries surfaces was significantly higher when 38% SDF was applied (2.5–4.5) compared to comparators (1.3–1.8)


1 3

(Duangthip et al. 2015; Jabin et al. 2020). Caries arrest rate of 38% SDF was significantly higher than other SDF concentrations (12%) (p < 0.001) (Tolba et al. 2019; Jabin et al. 2020) and caries excavation prior to its application did not significantly affect the caries arrest rate (Duangthip

et al. 2015). However, one SR reported that excavation of soft dentine prior to SDF application resulted in shorter caries arrest time (Trieu et al. 2019). For the comparators the effectiveness were 41% for 5% NAF fluoride varnish, 82% for GIC, and 15–34% for no treatment.

Records identified through database searching (n=252)

Scre

enin

gIn

clud

edEl

igib

ility

Iden

�fica

�on

Additional records identified through other sources (n=4)

Records after duplicates removed(n=181)

Records excluded (n=111)

Full-text articles excluded, with reasons (n=52)

Were narrative review (n=21)Assessed prevention of caries (n=10)Included permanent teeth (n=5)Results from primary and adult teeth pooled together (n= 15)Included enamel and dentine carries (1)

Inclusion & exclusion criteria applied

Records screened (n=70)

Full-text systematic reviews assessed for eligibility (n=70)

No. of systema�c

reviews focus on Atrauma�c Restora�ve Treatment

(n=8)

No. of systema�c

reviews focus on Silver Diammin

Fluoride (n=8)

No. of systema�c

reviews focus on selec�ve caries

removal (n=1)

No. of systema�c

reviews focus on the Hall

technique (n=1)

No. of systematic reviews (n=18)without metanalysis (n=5); with metanalysis (n=13)

Fig. 1 Flow diagram: identification and study selection


1 3

One meta-analysis reported an overall proportion of caries arrest for 38% SDF was 81% (p < 0.001) (Gao et al. 2016). Another meta-analysis reported an odds ratio of 2.44–3.63 favouring SDF for caries arrest (Trieu et al. 2019).

No significant adverse effects were reported from the use of 38% SDF in children other than black staining potential of SDF on carious lesions. One SR assessed carer satisfac-tion with their child’s dental appearance after the application of 38% SDF compared to comparators including placebo as well as 5% NAF, and found no significant change in the results across the intervention and control group (Trieu et al. 2019). In addition, one study reported the development of reversible, small, white lesions in the oral mucosa (0.6%) (Contreras et al. 2017).

Further details of the included SRs are presented in Tables 4 and 5.

Hall Technique for managing dentine carious lesions in primary teeth

Two SRs including three RCTs with meta-analysis compar-ing the HT to different comparators were included (Ricketts et al. 2013; Innes et al. 2015). However, the SR by Ricketts

et al. (2013) aimed to assess different operative caries man-agement techniques in children and adults including selec-tive caries removal, stepwise removal and the HT. With regards to the HT, the SR included one primary RCT (Innes et al. 2007) of which the results were also included in the second SR (Innes et al. 2015) with longer follow-up period, and therefore, this was not reported in details in the cur-rent umberlla review. Comparators included non-selective or selective caries removal followed with restoration (GIC, amalgam, composite, conventional preformed metal crowns (PMCs)) or NRCC. Outcome measures were divided into primary outcomes including major failure, reported pain, and satisfaction with dental treatment. Whereas secondary outcomes involved time to restoration failure (retreatment), discomfort associated with procedure, cost, and adverse events. Children ranged in their age between 3 and 10 years. Primary molars with single and multi-surface cavities were included and followed-up for 1–5 years.

Results from this SR regarding the HT as compared to non-selective caries removal to hard dentine showed no significant difference in sign/symptoms of pulpal disease between the two treatment arms. However, a significant reduction in the risk of restoration failure was reported in favour of the HT; 3% in the intervention group compared to

Table 1 Risk of bias according to ROBIS and assessment used in systematic review

Author year ROBISRisk of bias

Assessment used

Silver diamine fluoride Duangthip (2015) High Risk Cochrane risk of bias assessment tool Duangthip (2016) High risk Cochrane risk of bias assessment tool Gao (2016) Unclear risk Cochrane collaboration common scheme for bias Contreras (2017) High risk Cochrane risk of bias assessment tool Chibinski (2017) High risk Cochrane risk of bias assessment tool Trieu (2019) Low risk Cochrane risk of bias assessment tool Talbo (2019) Low risk Cochrane collaboration common scheme for bias Jabin (2020) High risk Oxford centre for evidence-based medicine critical appraisal

worksheet for controlled clinical trialsAtraumatic restorative technique Van’t Hof (2006) High risk No risk of bias conducted Michenautsch (2012) High risk Cochrane collaboration common scheme for bias Raggio (2013) High risk Quality score criteria for therapy articles Dorri (2017) Low risk Cochrane risk of bias assessment tool Tedesco (2017) Low risk Cochrane risk of bias assessment tool Tedesco (2018) Unclear risk Cochrane collaboration common scheme for bias de Amorim (2018) High risk Cochrane risk of bias assessment tool Ortiz-Ruiz (2020) High risk Not mentioned, a funnel plot was used to evaluate publication bias

Hall technique Innes (2015) Low risk Cochrane risk of bias assessment tool

Selective caries removal Rickets (2013) Low risk Cochrane risk of bias assessment tool


1 3

Tabl

e 2

Sum

mar

y of

incl

uded

syste

mat

ic re

view

s cha

ract

erist

ics

Aut

hor

Year

of

publ

ica-

tion

Type

s of s

tudi

esN

umbe

r of

stud

-ie

s

Ran

ge o

f pub

licat

ion

Met

a-an

alys

is

cond

ucte

d

Gra

ding

tool

use

dFu

ndin

g So

urce

Syste

mat

ic re

view

s on

silv

er

diam

ine

fluor

ide

Dua

ngth

ip e

t al

2015

RCTs

220

02–2

012

No

Coc

hran

e ris

k of

bia

s ass

essm

ent

tool

Facu

lty o

f Den

tistry

, Uni

vers

ity o

f H

ong

Kon

g D

uang

thip

et a

l20

16RC

Ts1

2012

No

Coc

hran

e ris

k of

bia

s ass

essm

ent

tool

Non

e st

ated

Gao

et a

l20

16RC

Ts &

CRT

s12

1969

–201

2Ye

sC

ochr

ane

colla

bora

tion

com

mon

sc

hem

e fo

r bia

sN

one

stat

ed

Con

trera

s et a

l20

17RC

Ts3

2005

–201

2N

oC

ochr

ane

risk

of b

ias a

sses

smen

t to

olN

atio

nal I

nstit

utes

of H

ealth

Aw

ard

No.

HC

TREC

D R

25M

D00

7607

an

d H

iREC

S21

MD

0018

30 fr

om

the

Nat

iona

l Ins

titut

e on

Min

ority

H

ealth

and

Hea

lth D

ispa

ritie

s C

hibi

nski

et a

l20

17RC

Ts5

2002

–201

3Ye

sC

ochr

ane

risk

of b

ias a

sses

smen

t to

olN

atio

nal C

ounc

il fo

r Sci

entifi

c an

d Te

chno

logi

cal D

evel

opm

ent (

CN

Pq)

unde

r gra

nts 3

04,1

05/2

013–

9 an

d 30

5,58

8/20

14–1

Trie

u et

al

2019

RCTs

320

01–2

016

Yes

Coc

hran

e ris

k of

bia

s ass

essm

ent

tool

Scho

ol o

f Den

tal M

edic

ine,

Uni

ver-

sity

of N

evad

a, U

SA T

olba

et a

l20

19RC

Ts3

2009

–201

8N

oC

ochr

ane

colla

bora

tion

com

mon

sc

hem

e fo

r bia

sN

one

stat

ed

Jabi

n et

al

2020

RCTs

& C

RTs

420

02–2

018

No

Oxf

ord

Cen

tre fo

r Evi

denc

e-ba

sed

Med

icin

e cr

itica

l app

rais

al w

ork-

shee

t for

con

trolle

d cl

inic

al tr

ials

Non

e st

ated

Syste

mat

ic R

evie

ws o

n A

traum

atic

Re

stora

tive

Trea

tmen

t v

an ‘t

Hof

et a

l20

06N

ot st

ated

919

99–2

004

Yes

No

risk

of b

ias c

ondu

cted

Non

e st

ated

Mic

kena

utsc

h et

al

2010

RCTs

and

CRT

s3

2002

–200

4Ye

sC

ochr

ane

colla

bora

tion

com

mon

sc

hem

e fo

r bia

sN

one

stat

ed

Rag

gio

et a

l20

13RC

Ts3

2002

–200

6Ye

sQ

ualit

y sc

ore

crite

ria fo

r the

rapy

ar

ticle

sN

one

stat

ed

Dor

ri et

al

2017

RCTs

620

03–2

007

Yes

Coc

hran

e ris

k of

bia

s ass

essm

ent

tool

The

Uni

vers

ity o

f Man

ches

ter,

Man

ches

ter A

cade

mic

Hea

lth S

ci-

ence

s Cen

tre (M

AH

SC),

UK

NIH

R

Man

ches

ter B

iom

edic

al R

esea

rch

Cen

tre, U

K T

edes

co e

t al

2017

RCTs

420

02–2

014

Yes

Coc

hran

e ris

k of

bia

s ass

essm

ent

tool

Non

e st

ated

Ted

esco

et a

l20

18RC

Ts a

nd

obse

rvat

ory

studi

es

1520

02–2

016

Yes

Coc

hran

e co

llabo

ratio

n co

mm

on

sche

me

for b

ias

Non

e st

ated


1 3

Tabl

e 2

(con

tinue

d)

Aut

hor

Year

of

publ

ica-

tion

Type

s of s

tudi

esN

umbe

r of

stud

-ie

s

Ran

ge o

f pub

licat

ion

Met

a-an

alys

is

cond

ucte

d

Gra

ding

tool

use

dFu

ndin

g So

urce

de

Am

orim

et a

l. (2

018)

2018

RCTs

12N

ot st

ated

Yes

Coc

hran

e ris

k of

bia

s ass

essm

ent

tool

Nat

iona

l Cou

ncil

for S

cien

tific

and

Tech

nolo

gica

l Dev

elop

men

t fro

m th

e B

razi

lian

Gov

ernm

ent,

unde

r gra

nts 3

09,5

21/2

015–

7 an

d 30

6,85

2/20

16–0

Orti

z-Ru

iz e

t al.

(202

0)20

20RC

Ts a

nd C

RTs

420

01–2

010

Yes

Not

men

tione

d, A

funn

el p

lot w

as

used

to e

valu

ate

publ

icat

ion

bias

Non

e st

ated

Syste

mat

ic re

view

s on

Hal

l tec

h-ni

que

Inne

s et a

l20

15RC

Ts2

2011

–201

4Ye

sC

ochr

ane

risk

of b

ias a

sses

smen

t to

olSc

hool

of D

entis

try, T

he U

nive

rsity

of

Man

ches

ter,

UK

Coc

hran

e O

ral H

ealth

Gro

up G

loba

l A

llian

ce, O

ther

Nat

iona

l Ins

titut

e fo

r Hea

lth R

esea

rch

(NIH

R),

UK

Syste

mat

ic re

view

s on

sele

ctiv

e ca

r-ie

s rem

oval

Ric

kets

et a

l20

13RC

Ts a

nd4

1977

–200

9Ye

sC

ochr

ane

risk

of b

ias a

sses

smen

t to

olU

nive

rsity

of D

unde

e D

enta

l Sch

ool,

UK

Guy

’s, K

ing’

s and

St T

hom

as

Den

tal S

choo

l, U

K. C

ochr

ane

Ora

l H

ealth

Gro

up G

loba

l Alli

ance

, U

K. N

atio

nal I

nstit

ute

for H

ealth

Re

sear

ch (N

IHR

), U

K


1 3

Table 3 Primary included studies included in the systematic reviews for dentine carious lesions management in primary teeth

Primary included studies Systematic reviews on silver diamine fluoride*

Duangthip (2015)

Duangthip (2016)

Gao (2016) Contreras (2017)

Chibinski (2017)

Trieu (2019) Tolba (2019) Jabin (2020)

Yoshida (1976) XTsutsumi (1981) XWang (1984) XYe (1995) XFukumoto (1997) XLo (2001) XChu (2002) X X X X XLlodra (2005) X X X XWong (2005) XHuang (2006) XYee (2009) X X X X XWong (2011) XZhi (2012) X X X X XSeberol (2013) XFung (2016) XFung (2018) X X

Primary included studies Systematic reviews on atraumatic restorative treatment**

Van’t Hof (2006)

Michenautsch (2012)

Raggio (2013) Dorri (2017) Tedesco (2017) Tedesco (2018) de Amorim (2018)

Ortiz-Ruiz (2020)

Lo (2001) X X XYee (2001) XTaifour (2002) X X X X X XLouw (2002) X X XLin (2003) XHonkala (2003) X X X X X XSchriks (2003) XErsin (2006) X X XVan den Dungen (2004) X XYu (2004) X X X X XDe Menezes (2006) X XRoeleveld (2006) XErsin (2006) X XVan Gemert-Schriks (2007) XErsin (2008) XYassen (2009) XCarvalho (2010) XMijan (2014) XDeepa (2010) XHilgert (2014) XMolina (2017) XHilgert (2017) X

Primary included studies Systematic reviews on the Hall technique

Ricketts (2013) Innes (2015)

Innes (2007) XSantamaria (2014) X


1 3

37% in the control group. In addition, more than two-thirds (77%) of the children, and 83% of the carers participated in the primary study preferred HT to non-selective caries removal to hard dentine. In relation to pain as assessed by the dentist, 89% of the children were assessed as experienc-ing “no pain, discomfort” to “mild, not significant” during the HT intervention, compared to 78% in the control group.

The SR by Innes (2015) did not compare the effectiveness and safety of HT to comparators, however the findings of the study favoured PMCs to conventional restoration particularly when HT was used as they were likely to reduce the risk of major failure or pain as well as discomfort associated at the time of treatment and in the long term. PMCs despite the technique used to place them, were found to cause more gingival bleeding, however, the results were inconclusive (RR 1.09, CI 0.42–2.86).

There was limited data to assess whether conventional PMCs were better than non-restorative caries treatment.


Selective removal of carious tissue

One SR with meta-analysis summarising data from 3 RCTs was included (Ricketts et al. 2013). In this SR, stepwise excavation, and selective caries removal were compared to non-selective caries removal to hard dentine. Single and multiple-surface cavities with caries extending to pulpal half or pulpal quarter of dentine in primary molars were

included. However, one study did not specify caries depth. Children ranged in their age between 3 and 11 years. In stepwise excavation and selective removal of caries, one study excavated caries until the operator determined there was a significant risk of pulp exposure with further exca-vation, while in the other two studies, caries was removed only from enamel–dentine junction along with superficial necrotic dentine from pulpal and axial walls of the cavity. No further attempt was made to remove dentinal caries. Interventions were followed-up for 12 months. Treatment outcomes were divided into primary outcomes including exposure of the dental pulp during caries removal, devel-opment of signs/symptoms suggestive of pulpal disease, caries progression, and restoration failure. Whereas sec-ondary outcomes involved oral health related quality of life, patient/carer perceptions of treatment, and patient reported discomfort during treatment.

Data related to stepwise excavation reported no cases of pulp exposure at first entry compared to 14.5% at sec-ond entry. Authors reported 69% reduction in risk of pulp exposure in primary molars with stepwise excavation com-pared to non-selective caries removal to hard dentine (RR 0.31, 95% CI 0.17–0.57, p = 0.0002).

With regards to development of signs/symptoms sug-gestive of pulp necrosis, one study reported one case (1.8%) of pulp necrosis in the stepwise excavation inter-vention arm compared to three cases (5.5%) in the con-trol arm. However, it was not clear from the publication whether this was a finding at excavation or on review.

*Overlap calculation for SDF SRs:Overlap = number of articles that reviewed by more than one reviewer/total number of articles = 5/16 = 0.3125CA (Covered area) = total number of reviewing/number of articles*number of reviewer = 4 + 3 + 4 + 5 + 3 + 10 + 1 + 2/16*8 = 32/128 = 0.25CCA (Corrected cover area) = (32–16)/(128–16) = 0.143 slight**Overlap calculation for ART SRs:Overlap = number of articles that reviewed by more than one reviewer/total number of articles = 9/22 = 0.41CA (Covered area) = total number of reviewing / number of articles*number of reviewer = 6 + 3 + 3 + 6 + 4 + 7 + 12 + 4/22*8 = 45/176 = 0.256CCA (Corrected cover area) = (45–22)/(176–22) = 0.15 slight

Table 3 (continued)

Primary included studies Systematic reviews on the Hall technique

Ricketts (2013) Innes (2015)

Innes (2011) X

Primary included studies Systematic reviews on selective caries removalRicketts (2013)

Magnusson (1977) XRibeiro (1999) XLula (2009) XOhran (2010) X


1 3

Selective caries removal was also found to reduce the risk of pulp exposure by 77% compared to non-selective caries removal to hard dentine in the primary molars (RR 0.24, 95% CI 0.06–0.90; p = 0.03) with no difference in pulpal disease between the two treatment arms (RR 0.27, 95% CI 0.05–1.60, p = 0.15).


Atraumatic restorative treatment for managing dentine carious lesions

In total, the 8 included SRs on ART reported on 56 clini-cal trials. The majority of these SRs included RCTs, CCT, and observational studies except one study by Van’t Hof (2006), which did not report on the type of studies included. Meta-analyses were conducted in the eight included SRs to synthesize the findings.

There was weak overlap between the SRs (Table 3). Although one primary study (Honkala et al. 2003) was included in six of the eight reviews, none of the reviews had complete overlap.

Three different outcome measures were assessed in the SRs: survival rate of restoration (van’t Hof et al. 2006; Raggio et al. 2013; Tedesco et al. 2017), caries arrest (de Amorim et al. 2018; Tedesco et al. 2018), and success/fail-ure of restoration (Mickenautsch and Yengopal 2012; Dorri et al. 2017; de Amorim et al. 2018; Tedesco et al. 2018; Ortiz-Ruiz et al. 2020).

Six SRs included carious primary teeth without speci-fying the type of teeth (Mickenautsch and Yengopal 2012; Raggio et al. 2013; Dorri et al. 2017; de Amorim et al. 2018; Tedesco et al. 2018; Ortiz-Ruiz et al. 2020), while two SRs specified primary molars (van’t Hof et al. 2006; Tedesco et al. 2017). Five SRs included single and multi-surface carious lesions (van’t Hof et al. 2006; Mickenautsch and Yengopal 2012; Dorri et al. 2017;

Table 4 Study parameters of systematic reviews on silver diamine fluoride

Author Number of subjects

Age range Tooth type Surface affected

Caries depth Presence of preoperative radiographs

Pulpal condition

Control Follow-Up

Duangthip et al. (2015)

587 2–5 years Primary teeth

Not stated Dentine caries

No Not stated No treat-ment, GIC, 5% NaF

24–30 months

Duangthip et al. (2016)



No Not stated No treat-ment, ART, NAF 5%, saline, GIC seal-ant

24 months

Gao et al Not stated Not stated Primary teeth

Not stated Not stated No Not stated No treat-ment, GIC, 5% NaF

6–48 months

Contreras et al


Not stated Not stated No Not stated No treat-ment, GIC sealant

24–36 months

Chibinski et al


Not stated Not stated No Not stated No treat-ment, ART, NaF vanish, saline

18–36 months

Trieu et al 1054 4 ± 0.8 years Primary teeth


No Not stated Water, 5% NaF

18–30 months

Tolba et al 1864 3–9 years Upper ante-rior teeth


No Not stated No treat-ment, SDF 12%

18–30 months

Jabin et al 2691 3–9 years Primary teeth

Single and multi surfaces

Not stated No Not stated No treat-ment, 12% SDF, 5% NaF, water

24–36 months


1 3

Tabl

e 5

Res

ults

of s

yste

mat

ic re

view

s on

silv

er d

iam

ine

fluor

ide

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of m

eta-

anal

ysis

Mai

n co

nclu

sion

Adv

erse

eve

nts

Dua

ngth

ip e

t al (

2015

)C

arie

s arr

est

Succ

essf

ul-C

arie

s arr

est r

ate

at 1

yr;

37%

if S

DF

appl

ied

1 × a

year

)53

% if

SD

F ap

plie

d 2 ×

a ye

ar-C

arie

s arr

est r

ate

at 2

yea

rs;

79%

if S

DF

appl

ied

1 × a

year

,91

% if

SD

F ap

plie

d 2 ×

a ye

ar-N

o di

ffere

nce

betw

een

annu

al

appl

icat

ion

of G

IC a

nd S

DF

-SD

F ap

plic

atio

n 2 ×

a ye

ar

incr

ease

d ca

ries a

rres

t rat

e-m

ean

num

ber o

f arr

este

d ca

ries;

2.

5 (w

hen

carie

s was

exc

avat

ed

and

38%

SD

F ap

plie

d), 2

.8 (n

o ca

ries e

xcav

atio

n an

d sd

f), 1

.5

(NA

F w

ith o

r with

out e

xcav

atio

n 4 ×

year

), 1.

3 (n

o tx

)-N

o di

ffere

nce

in c

arie

s arr

est r

ate

betw

een

exca

vatio

n or

no

Not

car

ried

out

Lim

ited

evid

ence

to su

ppor

t eff

ectiv

enes

s of S

DF

appl

icat

ion

once

/twic

e a

year

Bla

ck st

aini

ng

Dua

ngth

ip e

t al.

(201

6)C

arie

s arr

est

Succ

essf

ul-C

arie

s arr

est r

ates

whe

n SD

F ap

plie

d on

ce a

yea

r, an

d tw

ice

a ye

ar a

t 24

mon

ths r

evie

w w

ere

79%

, 91%

, res

pect

ivel

y-E

ffect

of a

nnua

l SD

F an

d G

I ap

plic

atio

n on

arr

estin

g ca

ries

did

not d

iffer

sign

ifica

ntly

ART

succ

ess:

39%

at 1

yea

r, 3.

5%

at 2

yea

rs; 4

8% si

ngle

surfa

ce v

s 52

% m

ultis

urfa

ceA

RT c

arie

s arr

est:

39%

at 1

yea

r, 82

% a

t 2 y

ears

Not

car

ried

out

Min

imal

ly in

vasi

ve a

ppro

ache

s ar

e ad

vant

ageo

us in

trea

ting

dent

in c

arie

s in

prim

ary

teet

h in

pr

esch

ool

Non

e st

ated

Gao

et a

lC

arie

s arr

est

Succ

essf

ul-I

f 38%

SD

F ap

plie

d on

ce a

yea

r ca

ries a

rres

t rat

e w

as;

31–7

9%-I

f app

lied

twic

e a

year

:85–

91%

-Car

ies a

rres

t rat

e at

6m

o w

as

86%

, at 1

2mo

was

81%

, at 1

8mo

was

78%

, at 2

4 m

o w

as 6

8%, a

nd

at >

30m

o w

as 7

1%-O

vera

ll pr

opor

tion

of c

arie

s arr

est

was

81%

(95%

CI,

68–8

9%;

p < 0.

001)

38%

SD

F ha

s sta

tistic

ally

sig-

nific

ant c

arie

s arr

est e

ffect

on

child

ren.

Incr

ease

d ap

plic

atio

n fr

eque

ncy

incr

ease

s car

ies a

rres

t ra

teN

o co

nsen

sus o

n its

num

ber a

nd

freq

uenc

y of

app

licat

ion

to a

rres

t ca

ries

Bla

ck st

aini

ng o

f tee

th


1 3

Tabl

e 5

(con

tinue

d)

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of m

eta-

anal

ysis

Mai

n co

nclu

sion

Adv

erse

eve

nts

Con

trera

s et a

lC

arie

s arr

est

Car

ies a

rres

t rat

e w

as si

gnifi

cant

ly

high

er (5

3%) w

hen

38%

SD

F w

as a

pplie

d tw

ice

a ye

ar th

an

whe

n 38

% S

DF

(37%

) or G

IC

(28.

6) w

as a

pplie

d an

nual

ly

(p <

0.00

1)38

% S

DF,

with

or w

ithou

t tea

, w

as si

gnifi

cant

ly m

ore

effici

ent

in c

arie

s arr

est i

n th

e pr

imar

y de

ntiti

on, a

t 12

mon

ths,

than

12

% S

DF

and

a co

ntro

l gro

up

(p <

0.00

1)

Not

car

ried

out

SDF,

at 3

8%, i

s mor

e eff

ectiv

e th

an

othe

r pre

vent

ive

man

agem

ent

strat

egie

s for

arr

estin

g de

ntin

al

carie

s in

the

prim

ary

dent

ition

Bla

ck st

ains

; whi

te le

sion

s in

oral

m

ucos

a in

3 p

artic

ipan

ts

Chi

bins

ki e

t al

Car

ies a

rres

tSu

cces

sful

-Mea

n nu

mbe

r of a

ctiv

e ca

rious

su

rface

at b

asel

ine

vs n

umbe

r of

inac

tive

at fo

llow

-up;

At 3

0 m

onth

s fol

low

-up:

3.8

2 (S

D

0.27

) vs 2

.49(

SD 0

.27)

follo

win

g ca

ries e

xcav

atio

n an

d SD

F 38

%4.

32 (0

.34)

vs 2

.82

(0.3

) whe

n 38

%

SDF

was

app

lied

with

no

carie

s ex

cava

tion

At 3

6 m

onth

s: 3

.3 (0

.3) v

s 2.8

(0.3

)A

t 24

mon

ths:

7.9

(7.6

) vs 6

.6 (6

.4)

with

38%

SD

F al

one

and

8.3

(8.5

) vs 7

.2 (7

.6) w

hen

SDF

38%

w

as a

pplie

d w

ith re

duci

ng a

gent

Car

ried

out b

ut a

ll pr

opor

tions

of

SDF

wer

e in

clud

edSD

F is

mor

e eff

ectiv

e th

an o

ther

ac

tive

treat

men

ts o

r pla

cebo

for

carie

s arr

est i

n pr

imar

y te

eth

Bla

ck st

ains

wer

e re

porte

d in

stud

ies

usin

g 38

% S

DF


1 3

Tabl

e 5

(con

tinue

d)

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of m

eta-

anal

ysis

Mai

n co

nclu

sion

Adv

erse

eve

nts

Trie

u et

al

Car

ies a

rres

tSu

cces

sful

-Sta

tistic

al si

gnifi

cant

diff

eren

ce

in c

arie

s arr

est r

ate

by S

DF

com

-pa

red

to N

AF

varn

ish

and

wat

er-P

aren

tal s

atis

fact

ion

with

thei

r ch

ild’s

den

tal a

ppea

ranc

e an

d de

ntal

hea

lth d

id n

ot si

gnifi

cant

ly

chan

ge (p

< 0.

05)

-sof

t tis

sue

rem

oval

prio

r to

SDF

appl

icat

ion

did

not i

nduc

e si

g-ni

fican

t diff

eren

ce in

car

ies a

rres

t (c

l95%

)-3

8% S

DF

resu

lted

in a

shor

ter

arre

st tim

e co

mpa

red

to N

AF

varn

ish

-Sof

t tis

sue

exca

vatio

n re

sulte

d in

sh

orte

r car

ies a

rres

t tim

e th

an n

o ex

cava

tion

OR

for c

arie

s arr

est =

2.44

–3.

63 >

1 fa

vour

ing

SDF

for t

he

incr

emen

t of a

rres

ted

carie

s ra

te,-C

hu: O

R is

2.4

4 fa

vour

ing

SDF

(incl

uded

30%

SD

F in

the

met

a an

alys

is)

SDF

is m

ore

effec

tive

dent

ine

car-

ies a

rres

ting

than

NA

FB

lack

stai

ning

Tolb

a et

al

Car

ies a

rres

tSu

cces

sful

-Sta

tistic

ally

sign

ifica

nt h

ighe

r m

ean

num

ber o

f arr

este

d ca

r-ie

s sur

face

s in

38%

SD

F vs

12

% S

DF

and

cont

rol a

t 6,1

2,

24 m

onth

s-C

arie

s arr

est r

ate

for 3

8% S

DF

at

6, 1

2 an

d 30

mon

ths w

ere

74%

, 64

%, a

nd 7

5.7%

resp

ectiv

ely

(p <

0.00

1)-B

iann

ual a

pplic

atio

n in

crea

sed

carie

s arr

est

Not

car

ried

out

Car

ies o

f prim

ary

teet

h in

chi

ldre

n tre

ated

with

38%

SD

F ha

d hi

gher

ch

ance

s of b

ecom

ing

arre

sted

than

thos

e tre

ated

with

12%

SDF.

H

ighe

r car

ies a

rres

t if a

pplie

d bi

annu

ally

rath

er th

an a

nnua

lly

asse

ssed

at 1

8 an

d 30

mon

ths.

If

38%

to b

e ap

plie

d on

ce a

yea

r, its

effe

ctiv

e bu

t its

effe

ctiv

enes

s in

arr

estin

g ca

ries d

ecre

ase

over

tim

e

Bla

ck st

aini

ng

Jabi

n et

al

Car

ies a

rres

tSu

cces

sful

-38%

SD

F ap

plie

d ev

ery

12 m

onth

s and

6 m

onth

s sho

wed

a

carie

s arr

est r

ate

of 6

6.9%

and

75

.7%

-Sin

gle

appl

icat

ion

of 3

8%

SDF

resu

lted

in (4

.5 ±

0.4)

or

(2.8

± 0.

3) a

rres

ted

lesi

ons,

mor

e th

an c

ontro

l gro

up (1

.8 ±

0.3)

-38%

SD

F is

mor

e eff

ectiv

e th

an

12%

SD

F-T

here

was

no

diffe

renc

e w

ith/

with

out r

educ

ing

agen

t (ta

nnic

ac

id)

Not

car

ried

out

38%

SD

F ap

plic

atio

n ca

n be

use

ful

in a

rres

ting

dent

al c

arie

sTh

ere

was

a d

iffer

ence

of 0

.6%

be

twee

n ad

vers

e ev

ents

reco

rded

be

twee

n te

st an

d co

ntro

l gro

ups

incl

udin

g na

usea

, not

eat

ing,

dys

-ph

agia

, dys

pnea

, sw

ellin

g ar

ound

lip

s and

face

, itc

hine

ss, r

ashe

s, sto

mac

h ac

he, a

nd d

iarr

hea

Exam

ined

effe

cts w

ere

ging

ival

or

muc

osal

ulc

erat

ion

or sw

ellin

g an

d bl

ack

disc

olor

atio

n


1 3

Tabl

e 6

Stu

dy p

aram

eter

s of s

yste

mat

ic re

view

s on

Hal

l Tec

hniq

ue

Aut

hor

Num

ber o

f sub

ject

sA

ge ra

nge

Toot

h ty

peSu

rface

affe

cted

Car

ies d

epth

Pres

ence

of p

reop

era-

tive

radi

ogra

phs

Pulp

al c

ondi

tion

Con

trol

Follo

w-U

p

Inne

s et a

l30

13–

10 y

ears

Prim

ary

mol

ars

Sing

le a

nd m

ulti-

surfa

ceD

entin

e ca

ries l

Yes

Sym

ptom

less

, with

no

clin

ical

or

radi

ogra

phic

sign

s of

pulp

al p

atho

logy

Com

plet

e or

par

tial

carie

s rem

oval

(GIC

, am

alga

m, c

ompo

site

, co

nven

tiona

l SSC

) an

d no

n-re

stora

tive

carie

s tre

atm

ent,

no

resto

ratio

ns

1–5

year

s

Tabl

e 7

Res

ults

of s

yste

mat

ic re

view

s on

Hal

l Tec

hniq

ue

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of

met

a-an

alys

isM

ain

conc

lusi

onA

dver

se e

vent

s

Inne

s et a

l-P

rimar

y ou

tcom

es: m

ajor

failu

re,

pain

, sat

isfa

ctio

n w

ith tr

eatm

ent

-Sec

onda

ry o

utco

mes

: tim

e to

re

stora

tion

failu

re/re

treat

men

t, di

scom

fort

asso

ciat

ed w

ith p

ro-

cedu

re, c

ost,

adve

rse

even

ts

Min

or fa

ilure

-Adv

erse

eve

nts;

Cro

wns

seem

ed

to c

ause

mor

e gi

ngiv

al b

leed

ing:

re

sults

wer

e in

conc

lusi

ve (R

R

1.09

, CI 0

.42–

2.86

)-R

esul

ts c

once

rnin

g di

scom

fort

asso

ciat

ed w

ith H

T (r

epor

ted

as

mod

erat

e, in

tens

e, v

ery

inte

nse

durin

g Tx

) wer

e in

conc

lusi

ve

(RR

1.6

7, C

I 0.6

5–4.

25)

-Res

ults

con

cern

ing

disc

omfo

rt as

soci

ated

with

HT

(rep

orte

d as

m

oder

ate,

inte

nse,

ver

y in

tens

e du

ring

Tx) w

ere

inco

nclu

sive

(R

R 1

.67,

CI 0

.65–

4.25

)-A

dver

se e

vent

s; C

row

ns se

emed

to

cau

se m

ore

ging

ival

ble

edin

g:

resu

lts w

ere

inco

nclu

sive

(RR

1.

09, C

I 0.4

2–2.

86)

-Non

e of

the

incl

uded

stud

ies

com

pare

d th

e eff

ectiv

enes

s and

sa

fety

of H

T ve

rsus

con

ven-

tiona

l res

tora

tion

-Fin

ding

s fav

oure

d cr

owns

com

-pa

red

to c

onve

ntio

nal fi

lling

s pa

rticu

larly

whe

n H

T w

as u

sed,

th

ey a

re li

kely

to re

duce

risk

of

maj

or fa

ilure

or p

ain

in th

e lo

ng

term

com

pare

d to

con

vent

iona

l fil

lings

-HT

may

redu

ce d

isco

mfo

rt at

tim

e of

trea

tmen

t com

pare

d to

fil

lings

-The

re w

as li

mite

d da

ta to

ass

ess

whe

ther

cro

wns

are

bet

ter t

han

non-

resto

rativ

e ca

ries t

reat

men

t-T

here

was

no

data

to a

sses

s the

m

ost e

ffect

ive

tech

niqu

e fo

r us

ing

crow

ns (c

onve

ntio

nal v

s H

T)

Resu

lts c

once

rnin

g di

scom

fort

asso

ciat

ed w

ith H

T (r

epor

ted

as

mod

erat

e, in

tens

e, v

ery

inte

nse

durin

g Tx

) wer

e in

conc

lusi

ve (R

R

1.67

, CI 0

.65–

4.25

)


1 3

de Amorim et al. 2018; Tedesco et al. 2018), and three SRs included only multi-surface carious lesions (Raggio et al. 2013; Tedesco et al. 2017; Ortiz-Ruiz et al. 2020). Caries depth was only stated in two SRs (Tedesco et al. 2018; Dorri et al. 2017) and defined as lesions extending into dentine. Participants included in the primary stud-ies ranged in their age between 2 and 14 years and were followed-up up to 5 years (range 6 months to 5 years). One study did not report the sample size (Raggio et al. 2013).

Most SRs included studies comparing ART to different conventional restorations including amalgam, conventional GIC, and resin composite (Mickenautsch and Yengopal 2012; Raggio et al. 2013; Dorri et al. 2017; Tedesco et al. 2017). One SR (Tedesco et al. 2018) compared ART to NRCC, HT, and resin sealant. Three SRs did not specify the comparator but presented the original reported data (de Amorim et al. 2018; van’t Hof et al. 2006; Ortiz-Ruiz et al. 2020).

The success rate of single surface ART at 1-year fol-low-up ranged between 95 and 100%, the latter dropped slightly to 96.7–91% and 86% at 2-and 3-year follow-up, respectively (van’t Hof et al. 2006; Tedesco et al. 2018). The results for multi-surface ART cavities were signifi-cantly lower (p < 0.0001) where figures ranged between 73 and 100% at 1 year, 52 and 93% at 2 years, and 48.7 and 88% at 3-year follow-up (van’t Hof et al. 2006; Tedesco et al. 2017; Tedesco et al. 2018). Compared to the ART technique, success rate reported for the conventional restorative treatment using different types of restorations including amalgam, resin composite and conventional GIC, ranged between 100–33.6% and 100–42% for single and multi-surface lesions, respectively over 3 years.

With regards to ART restoration failure rate, two SRs reported a significantly higher mean annual failure rate for multi-surface cavities (17%) compared to single surface cavities (4.7–5%) in primary molars over the first 3 years of their placement (van’t Hof et al. 2006; de Amorim et al. 2018).

Three SRs showed that ART restorations had similar survival rates compared to conventional restoration with amalgam and resin composite in single and multi-surface cavities in primary molars (p > 0.05) (Mickenautsch and Yengopal 2012; Raggio et al. 2013; Tedesco et al. 2017].

Whereas one SR reported that ART may increase the risk of restoration failure (OR 1.60, CL 1.13–2.27) regardless of the number of surfaces involved compared to conven-tional restoration with amalgam, resin composite and conventional GIC in the primary dentition over follow-up period of 12–24 months (Dorri et al. 2017).

No significant adverse events associated with ART res-toration were reported by any of the included SRs. One SR reported that ART was associated with less discomfort in children aged 6–8 years compared to conventional treatment with local anaesthetic (OR 0.95, CL 0.51–1.79) (Dorri et al. 2017).

Reported ART results varied between SRs, generally due to the diverse criteria for assessing outcomes. However, the SRs showed homogeneously for primary teeth with regard to the mean survival rates of single-surface ART/HVGIC restorations that were significantly higher over 3 years as compared to multiple-surface ART/HVGIC restorations.


Study outcome summary of findings

Interventions involving no dentine carious tissue removal:

o Regarding fissure sealants and resin infiltration, the evidence available on these techniques were mainly for their sealing ability of enamel caries, and there-fore, they are not recommended for the management of dentinal caries lesions in primary teeth

Two techniques were considered as not involving removal of dentine carious tissue: topical applica-tion of 38% SDF and the HT.

o Regarding SDF, main results showed that 38% SDF applied every 12 months can be advantageous in terms of caries arrest, however biannual applica-tion of 38% SDF resulted in higher caries arrest rate vs single application. For 38% SDF, none of the included SRs reported the treatment effectiveness in terms of the depth of the carious lesions.

o For PMCs, findings favoured these in general com-pared to conventional restorations particularly when

Table 8 Study parameters of systematic reviews on selective caries removal



Caries depth Presence of preoperative radiographs

Pulpal condi-tion

Control Follow-up

Rickets et al 262 3–11 years Primary molars

Single and multisur-faces

Dentine caries

Yes Symptom-less, vital

Complete caries removal

12 months


1 3

the HT was used. The HT is likely to reduce the risk of major failure or pain in the long-term compared to conventional restorations including amalgam, GIC and resin composite. In addition, it seems that the HT may reduce discomfort at time of treatment compared to the conventional restorations.

o There was no available data to determine whether PMCs using the HT was better than the topical use of 38% SDF.

Interventions involving non-restorative caries treatment:

o Regarding NRCC, the evidence on this technique was very limited, and low in terms of quality. There-fore, no conclusions on this technique can be drawn.

Interventions involving selective caries removal:

o Selective and stepwise caries removal seem to reduce the risk of pulp exposure in asymptomatic, vital, carious primary teeth when these techniques were used to treat deep carious lesions (lesions extending into the inner third or quarter of dentine) over CCR.

o For selective caries removal (one-step), studies that did not re-enter the carious lesions reported no adverse consequences.

o Comparing selective caries removal (one-step) to stepwise caries, there was limited evidence to deter-mine the superiority of one over the other in terms of pulp symptoms.

o There is evidence showing that ART using HVGIC may be associated with the risk of restoration fail-ure for multi-surface cavities. However, ART using HVGIC showed to be an adequate management option for treating single-surface carious lesions in primary teeth.

Assessment of heterogeneity and systematic reviews’ risk of bias

A substantial heterogeneity was found between the final 18 included SRs mainly concerning subject characteristics, depth and extension of treated lesions, restorative materials used, and outcome measures. However, the trend of hetero-geneity was similar across all the studies. In addition, data-bases searched, and reporting criteria considerably differed among these SRs.

Most studies were found to have considerable risk of bias. Ten systematic reviews were at high risk of bias (Van’t Hof et al. 2006; Mickenautsch and Yengopal 2012; Raggio et al.

Tabl

e 9

Res

ults

of s

yste

mat

ic re

view

s on

sele

ctiv

e ca

ries r

emov

al

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of m

eta-

anal

ysis

Mai

n co

nclu

sion

Adv

erse

eve

nts

Ric

kets

et a

lPr

imar

y ou

tcom

e: e

xpos

ure

of th

e de

ntal

pul

p du

ring

carie

s rem

oval

, si

gns/

sym

ptom

s of p

ulpa

l dis

ease

, pr

ogre

ssio

n of

car

ies,

and

resto

ratio

n fa

ilure

Seco

ndar

y ou

tcom

es: o

ral h

ealth

re

late

d qu

ality

of l

ife, p

atie

nt/c

arer

pe

rcep

tions

of t

reat

men

t, an

d pa

tient

di

scom

fort

durin

g tre

atm

ent

Succ

ess;

For p

rimar

y te

eth,

ther

e w

as a

re

duct

ion

in ri

sk fa

vour

ing

parti

al

carie

s rem

oval

(RR

0.2

4 (9

5% C

I 0.

06–0

.90;

p =

0.03

, I2 =

0%)

Failu

re:

3 stu

dies

(2 o

n pr

imar

y te

eth

and

one

incl

uded

bot

h pr

imar

y an

d ad

ult

teet

h):

Ther

e w

as n

o di

ffere

nce

in p

ulpa

l di

seas

e be

twee

n pa

rtial

and

com

plet

e ca

ries r

emov

al (R

R 0

.27,

95%

CI

0.05

–1.6

0, p

= 0.

15, I

2 = 0%

Step

wis

e ex

cava

tion:

for p

rimar

y te

eth,

th

e ris

k ra

tio fo

r pul

pal e

xpos

ure

durin

g ste

pwis

e ex

cava

tion

was

RR

0.

31 (9

5% C

I 0.1

7–0.

57, p

= 0.

0002

, I2

= 0%

) and

a 6

9% re

duct

ion

in ri

sk

resp

ectiv

ely

com

pare

d w

ith c

ompl

ete

carie

s rem

oval

Parti

al c

arie

s rem

oval

:2

studi

es c

ombi

ned

prim

ary

and

adul

t te

eth:

Ove

rall

ther

e w

as a

redu

ctio

n in

risk

of e

xpos

ure

of d

enta

l pul

p fa

vour

ing

parti

al c

arie

s rem

oval

(RR

0.

23 (9

5% C

I 0.0

8–0.

69, p

= 0.

009,

I2

= 0%

), a

77%

redu

ctio

n in

risk

of

pulp

exp

osur

e co

mpa

red

to c

ompl

ete

carie

s rem

oval

Step

wis

e an

d pa

rtial

exc

avat

ion

redu

ced

the

inci

denc

e of

pul

p ex

po-

sure

in sy

mpt

omle

ss, v

ital,

cario

us

prim

ary

teet

h

Non

e


1 3

2013; Duangthip et al. 2015, Duangthip et al. 2016, Chib-inski et al. 2017, Contreras et al. 2017, de Amomrim et al. 2018; Jabin et al. 2020; Ortiz-Ruiz et al. 2020), six were at low risk of bias (Ricketts et al. 2013, Innes et al. 2015; Dorri et al. 2017; Tedesco et al. 2017, Trieu et al. 2019; Tolba

et al. 2019) and two were at unclear risk of bias (Gao et al. 2016, Tedesco et al. 2018).

Figure 2 and Table 1 present a summary of ROBIS assessment across all included reviews.

Table 10 Study parameters of systematic reviews on atraumatic restorative treatment



Caries depth

Presence of preopera-tive radio-graphs

Pulpal condition

Control Follow-up

van ‘t Hof et al

Not stated 3 to > 6 years Primary molars

Single and multi-surface

Not stated No Not stated No control 3 years

Mick-enautsch et al

1926 fillings: 1052 ART and 874 Amalgam

5–7 years Primary teeth


Not stated No Not stated Amalgam 1–3 years

Raggio et al 1242 fill-ings: 715 HVGIC, 527 con-ventional

Not stated Primary teeth

Multi surface

Not stated No Not stated Amalgam and composite resin

2–3 years

Dorri et al 1107 3–13 years Primary teeth


Dentine caries

No No pulpal involve-ment

Amalgam, GIC (conven-tional), and composite resin

2–3 years

Tedesco et al (2017)

1771 fill-ings:

985 HVGIC, 786 con-ventional

2–11 years Primary molars

Multi surface

Not stated No Not stated Amalgam and composite resin

2–3 years

Tedesco et al. (2018)

3,226 2–10 years Primary teeth


Dentine caries

No Not stated Conven-tional restora-tive treatment, LVGIC, NaF, IRT, NRCT, ultracon-servative treatment, HT, seal-ing

6 months–5 years

de Amorim et al

Not stated 2–9 years Primary teeth


Not stated No Not stated No control 1–3 years

Ortiz-Ruiz et al

253 ART fillings

6–14 years Primary teeth

Multi surface

Not stated No Not stated No control 2 years


1 3

Tabl

e 11

Re

sults

of s

yste

mat

ic re

view

s on

atra

umat

ic re

stora

tive

treat

men

t

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of m

eta-

anal

ysis

Mai

n co

nclu

sion

Adv

erse

eve

nts

Van‘

t Hof

et a

lSu

rviv

al ra

teSu

cces

s-T

he m

ean

surv

ival

rate

s of s

ingl

e-su

rface

ART

resto

ratio

ns w

ere

stat

istic

ally

sign

ifica

ntly

hig

her

than

thos

e of

mul

tiple

-sur

face

A

RT re

stora

tions

in p

rimar

y te

eth

afte

r 1 a

nd 2

yea

rs (p

< 0.

0001

)-T

he m

ean

annu

al fa

ilure

rate

s of

sing

le-s

urfa

ce a

nd m

ultip

le-s

urfa

ce

ART

resto

ratio

ns in

prim

ary

teet

h ov

er th

e fir

st 3

year

s was

4.7

% a

nd

17%

, res

pect

ivel

y.-M

ean

surv

ival

ra

te fo

r sin

gle

surfa

ce H

VG

IC

ART

in p

rimar

y te

eth:

at 1

yea

r: 95

%at

2 y

ear:

91%

at 3

yea

rs: 8

6%-M

ean

surv

ival

rate

for m

ultis

urfa

ce

HV

GIC

ART

was

:at

1 y

ear:

73%

at 2

yea

r: 59

%at

3 y

ears

: 49%

-The

met

a-an

alys

is sh

owed

hig

h m

ean

surv

ival

resu

lts fo

r sin

gle-

surfa

ce A

RT re

stora

tions

in

prim

ary

dent

ition

s

-Hig

h m

ean

surv

ival

resu

lts fo

r si

ngle

-sur

face

ART

resto

ratio

ns in

pr

imar

y de

ntiti

ons

but t

hat t

he m

ean

annu

al fa

ilure

rate

fo

r mul

tiple

-sur

face

ART

resto

ra-

tions

rem

ains

rath

er h

igh

Non

e st

ated

Mic

kena

utsc

h et

al

Failu

re ra

teSu

ccess

Rela

tive

risk

of c

lass

I re

stora

tions

be

twee

n 0.

95 a

nd 1

.03

for A

RT v

s A

mal

gam

Rela

tive

risk

of c

lass

II re

stora

tions

be

twee

n 0.

89 a

nd1.

12 fo

r ART

vs

Am

alga

mTh

ere

is n

o st

atist

ical

ly si

gnifi

cant

di

ffere

nce

in th

e su

cces

s rat

es o

f cl

ass I

ART

and

am

alga

m re

stora

-tio

ns in

prim

ary

teet

h

The

rela

tive

risks

afte

r 12

and

24 m

onth

s (R

R 0

.93;

95%

CI 0

.83–

1.06

; p =

0.26

and

RR

1.

07; 9

5%C

I 0.9

1–1.

27;

p = 0.

39, r

espe

ctiv

ely)

of c

lass

I A

RT a

nd a

mal

gam

resto

ratio

ns in

prim

ary

teet

h

No

diffe

renc

es c

ould

be

foun

d in

the

prim

ary

dent

ition

stud

ies o

ver a

2-

year

follo

w-u

p pe

riod.

ART

res-

tora

tions

with

hig

h-vi

scos

ity G

IC

appe

ar to

be

equa

lly su

cces

sful

, an

d th

eir s

urvi

val r

ate

may

eve

n ex

ceed

that

of a

mal

gam

filli

ngs

Non

e st

ated

Rag

gio

et a

lSu

rviv

al ra

teSu

cces

s-S

ucce

ss ra

te o

f ART

var

ied

betw

een

48.7

and

88.

9%-P

oole

d es

timat

e fo

r ART

succ

ess

rate

was

1.0

4

-No

diffe

renc

e in

surv

ival

resu

lts

betw

een

amal

gam

and

ART

with

hi

gh v

isco

sity

GIC

in o

cclu

sopr

ox-

imal

cav

ities

in p

rimar

y te

eth

up

to 3

yea

r fol

low

up;

p >

0.05

(odd

s ra

tio ra

nged

bet

wee

n 0.

298–

1.26

7)

-No

diffe

renc

e in

surv

ival

resu

lts

betw

een

amal

gam

and

ART

with

hi

gh v

isco

sity

GIC

in o

cclu

so-

prox

imal

cav

ities

in p

rimar

y te

eth

up to

3-y

ear f

ollo

w-u

p

Non

e st

ated


1 3

Tabl

e 11

(c

ontin

ued)

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of m

eta-

anal

ysis

Mai

n co

nclu

sion

Adv

erse

eve

nts

Dor

ri et

al

Failu

re ra

te a

nd p

ain

Failu

re-R

esto

ratio

n fa

ilure

in th

e pr

i-m

ary

dent

ition

bet

wee

n 12

and

36

mon

ths:

1.60

(OR

) tim

es h

ighe

r in

the

ART

ar

m th

an in

the

conv

entio

nal a

rm

(95%

CI 1

.13–

2.27

)-C

avity

type

had

no

effec

t on

resto

-ra

tion

failu

re (p

= 0.

64)

-ART

may

redu

ce th

e pa

in d

ur-

ing

proc

edur

e co

mpa

red

with

co

ntro

l tre

atm

ent (

MD

-0.6

5, 9

5%

CI-

1.38

–0.0

7)-T

he o

dds o

f dis

com

fort

wer

e re

duce

d w

ith A

RT in

chi

ldre

n be

twee

n si

x an

d ei

ght y

ears

of a

ge

(OR

0.9

5,95

% C

I 0.5

1 to

1.7

9)

com

pare

d to

con

vent

iona

l tre

at-

men

t with

LA

-Com

pare

d to

con

vent

iona

l tre

atm

ent

usin

g H

-GIC

, ART

may

incr

ease

th

e ris

k of

resto

ratio

n fa

ilure

in th

e pr

imar

y de

ntiti

on o

ver a

follo

w-u

p pe

riod

from

12

to 2

4 m

onth

s-R

esto

ratio

n fa

ilure

: ART

GIC

vs

CT

GIC

1.6

0 [ 1

.13,

2.2

7] fo

r co

nven

tiona

lPa

in: A

RT G

IC v

s CT-

0.65

[− 1

.38,

0.

07]

-Com

pare

d to

con

vent

iona

l tre

at-

men

t usi

ng H

-GIC

, ART

may

in

crea

se th

e ris

k of

resto

ratio

n fa

ilure

in th

e pr

imar

y de

ntiti

on

over

a fo

llow

-up

perio

d fro

m 1

2 to

24

mon

ths

-ART

may

redu

ce p

ain

durin

g pr

oce-

dure

com

pare

d w

ith c

onve

ntio

nal

treat

men

t

Non

e st

ated

Tede

sco

et a

l. (2

017)

Surv

ival

rate

Succ

ess

-Sur

viva

l rat

e of

ART

:A

t 1 y

ear:

100%

, 83.

3%, 8

0.7%

At 2

yea

rs: 8

8.9%

, 76.

1%, 6

6.3%

At 3

yea

rs: 4

8.7%

, 56.

4%

-No

stat

istic

al si

gnifi

cant

diff

eren

ce

betw

een

ART

and

con

vent

iona

l re

stora

tion

(p: 0

.06,

OR

: 1.2

6. p

: 0.

477,

OR

: 0.2

98. p

: 0.3

41, O

R:

0.71

0. p

: 0.0

55, O

R: 0

.710

)

-ART

resto

ratio

ns h

ave

sim

ilar

surv

ival

rate

s com

pare

d to

con

ven-

tiona

l tre

atm

ent a

nd a

re a

via

ble

optio

n to

resto

re o

cclu

sopr

oxim

al

cavi

ties i

n pr

imar

y m

olar

s

Non

e st

ated


1 3

Tabl

e 11

(c

ontin

ued)

Aut

hor

Out

com

e m

easu

reM

ain

resu

ltsRe

sults

of m

eta-

anal

ysis

Mai

n co

nclu

sion

Adv

erse

eve

nts

Tede

sco

et a

l. (2

018)

Car

ies a

rres

t and

succ

ess o

f res

tora

-tio

nSu

ccess

-suc

cess

rate

of A

RT in

sing

le

surfa

ce:

at 1

yea

rs: 1

00%

& 9

6%at

2 y

ears

: 96.

7%, 9

2.3%

and

91.

4%,

at 3

yea

rs: 8

6.1%

-Suc

cess

rate

of A

RT in

mul

tisur

-fa

ce:

at 1

yea

r: 10

0% 9

7.7%

, 73%

, 88.

9%

and

83.1

%at

2 y

ears

: 93.

1%, 8

8.9%

, 76.

1% a

nd

52%

at 3

yea

rs: 9

3.4%

and

48.

7%at

3.5

yea

rs: 8

8%-S

ucce

ss ra

te o

f HT:

at 1

yea

r: 98

%at

5 y

ears

: 92%

-Suc

cess

of U

CT

in m

ultis

urfa

ce:

95.7

% a

t 1 y

ear,

88%

at 2

yea

rs a

nd

3 ye

ars

-Suc

cess

rate

of N

RCT

at 1

yea

r was

75

%-S

ucce

ss ra

te o

f res

in se

alan

ts:

at 1

yea

r was

91.

6% a

nd 7

5%at

1.5

yea

r was

64.

5%

-For

car

ies l

imite

d to

out

er th

ird o

f de

ntin

e of

occ

lusa

l sur

face

s, re

sin

com

posi

te sh

owed

hig

her s

ucce

ss

rate

than

seal

ing

with

resi

n se

alna

t.no

diff

eren

ce w

as fo

und

betw

een

resi

n se

alan

ts a

nd C

T in

term

s of

carie

s arr

est

-For

all

occl

usal

surfa

ces,

CRT

with

co

mpo

mer

had

hig

hest

succ

ess

rate

> A

RT

-For

occ

luso

prox

imal

, H

T ha

d hi

ghes

t suc

cess

ra

te >

NRC

T >

CTR

> A

RT >

UC

T -F

or o

cclu

sal a

nd sm

ooth

sur-

face

s car

ies a

rres

t, hi

ghes

t arr

est

with

bia

nnua

l app

licat

ion

of

38%

SDF

> 3

× N

2F >

IRT

-Tre

atm

ent o

f den

tine

carie

s in

pri-

mar

y te

eth

depe

nds o

n pr

ogre

ssio

n de

pth

and

surfa

ce in

volv

ed-F

ew st

udie

s exi

st w

ith h

igh

risk

of

bias

to p

rovi

de e

vide

nce

to th

e be

st tre

atm

ent o

ptio

n

Non

e st

ated

de A

mor

im e

t al

Car

ies a

rres

t and

failu

re ra

teFa

ilure

-The

wei

ghte

d m

ean

annu

al fa

ilure

ra

tes f

or si

ngle

and

mul

tiple

sur-

face

ART

resto

ratio

ns in

prim

ary

poste

rior t

eeth

ove

r the

firs

t 3 y

ears

w

ere

5 an

d 17

%, r

espe

ctiv

ely

Sim

ilar t

o th

e m

ain

resu

lts-S

urvi

val o

f sin

gle

surfa

ce H

VG

IC

ART

in p

oste

rior p

rimar

y te

eth

over

the

first

3 ye

ars i

s hig

h,

whe

reas

for m

ultip

le su

rface

ove

r 2

year

s is a

t med

ium

leve

l-C

ompa

red

to th

e re

sults

from

pr

evio

us S

R (1

2 ye

ars o

lder

), A

RT

show

ed a

n eff

ectiv

e op

tion

for

man

agin

g ca

ries i

n pr

imar

y te

eth

rath

er th

an a

s an

alte

rnat

ive

optio

n

Non

e st

ated

Orti

z-Ru

iz e

t al

Rete

ntio

n, m

argi

nal i

nteg

rity,

an

atom

ic fo

rm a

nd a

bsen

ce o

f re

curr

ent c

arie

s

Success

-Ret

entio

n su

cces

s rat

e of

ART

: 0.

93, 0

.75,

0.1

2-A

bsen

ce o

f rec

urre

nt c

arie

s 0.9

3,

0.91

, 0.7

2,

Sim

ilar t

o th

e m

ain

resu

lts-S

igni

fican

t rel

atio

n be

twee

n ca

vity

form

and

filli

ng m

ater

ial

with

wor

st co

mbi

natio

n be

twee

n H

VG

IC a

nd A

RT (p

< 0.

001)

Non

e st

ated


1 3

Discussion

This umbrella review aimed at investigating the available evidence with regards to the management of carious lesions into dentine in primary teeth using a minimal intervention approach without the need for using local anaesthetic. Due to the availability of many recent SRs, it became clear that an umbrella review approach should be adopted to avoid duplication of available evidence and to comprehensively cover all different techniques that fall under the umbrella of MID. This approach was also supported by the fact that the majority of the published SRs were looking at one modality of MID rather than the full range of techniques incorporated by this term. In total, 18 SRs met the inclusion criteria of the current review and were included in the final review, however, the majority of these reviews focused on 2 main techniques namely 38% SDF (8 SRs included) and ART (8 SRs included). This could be due to the fact that many of the more recently used techniques (e.g., application of SDF) are over taking more established techniques such stepwise and selective caries removal. In addition, we found only one SR looking at the HT (Innes et al. 2015) and another one aimed at assessing the efficacy of ultra-conservative removal of caries which included data on the HT (Tedesco et al. 2018). The latter has also included data on stepwise excavation and selective removal of caries. HT is relatively a new treatment modality which has recently started to have international acceptance. However, there are a couple of ongoing recently registered (PROSPERO; https:// www. crd. york. ac. uk/ prosp ero/# searc hadva nced) systematic reviews including one is carried out by the authors of the current umbrella review,

which will look at the different aspects of the Hall technique, and the results of these ongoing reviews will confidently add to the existing evidence.

As the current umbrella review aimed to investigate the outcomes of MID interventions in the management of den-tine rather than enamel caries, SRs assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded due to pooled data reporting on caries arrest in both enamel and outer third of dentine with the majority of these carious lesions being limited to enamel. Therefore, based on the results of the current review, both fissure sealants and resin infiltration are not recommended for the management of dentinal caries lesions in primary teeth.

The current review provides a broader view of MID in managing dentine carious primary teeth and might be use-ful to inform guidelines and clinical practice when all of the caries management options need to be contemplated. How-ever, when considering the findings of the current umbrella review, it is important to note that the authors did not analyse the primary studies and therefore the results are subject to the accuracy of the published SRs. In addition, following SR selection, it became clear that it would be difficult to analyse the findings based on the type of caries management inter-vention (see PICO description), instead each management technique (SDF, HT, selective removal of caries, stepwise and ART) was analysed on its own and the findings of dif-ferent techniques were brought together.

When included SRs concerning 38% SDF were assessed in the current umbrella review, there was a clearly wide variability in the number of the included primary studies,

Fig. 2 Bias according to ROBIS tool

https://www.crd.york.ac.uk/prospero/#searchadvanced

https://www.crd.york.ac.uk/prospero/#searchadvanced


1 3

ranging from 2 up to 12 studies, with some of these stud-ies dated back to 1969. This could be due to the different inclusion criteria adopted in these SRs. However, the main outcome of these reviews was similar (caries arrest). The majority of the included SRs reported a considerable risk of bias in the included studies, and only two SRs reported a low risk of bias even though the included primary studies overlapped (Trieu et al. 2019; Tolba et al. 2019). Independ-ent of the risk of bias, most SRs agreed that a single (annual) application of 38% SDF outperformed the comparators (flu-oride varnish, GIC, no treatment or placebo). In addition, the success rate of 38% SDF in arresting dental caries has increased when 38% SDF was applied twice rather than once a year (Duangthip et al. 2016; Gao et al. 2016; Duangthip et al. 2017; Tolba et al. 2019; Jabin et al. 2020). None of the included primary studies compared the topical application of 38% SDF to conventional restorations could explain the fact that this modality of treatment is currently used when conventional restorative techniques are perceived to be chal-lenging to perform. The main drawback reported of SDF application was the potential permanent black staining of carious lesions. One review (Trieu et al. 2019) reported that the latter was not a significant issue for the majority of the included carers in their review.

Looking at the SRs could be identified that authors included studies in which SDF was applied in high-caries-risk children presenting with asymptomatic dentine cari-ous primary teeth with no evidence of pulp damage. These aspects, although often reported in clinical studies, are hardly considered as a variable of analysis and this may influence the long-term success of treatment or might be a factor that should be considered together with the frequency of SDF application.

There is limited evidence from SRs on the HT. The cur-rent umbrella review identified only two reviews, both of which included the same primary studies (Ricketts et al. 2013; Innes et al. 2015). In general, our findings revealed that PMCs, favoured successful outcomes (tooth remained symptom-free in place through-out the follow-up time) com-pared to conventional restorations particularly when the HT was used. In addition, the HT is likely to reduce the risk of major failure (pulp treatment or extraction needed) or pain in the long-term compared to conventional restorations includ-ing amalgam, GIC and resin composite. In addition, it seems that the HT may reduce discomfort at time of treatment com-pared to conventional restorations. There is a clear need for a SR investigating the effectiveness of the HT as well as its cost effectiveness and acceptance by children and parent. An ongoing SR (PROSPERO 2020 CRD42020202442) is taking place in an attempt to answer these questions.

For the selective caries removal, the main limitation to reach conclusions was based on the limited number

of included studies with only one systematic review was included in this umbrella review (Ricketts et al. 2013). At the initial search, there was a large number of pub-lished reviews on selective caries removal, however, these were not included in the present umbrella review due to substantial heterogeneity of their inclusion criteria (i.e., use of local anaesthesia, pooled data reporting of primary and permanent teeth, the amount of tissue left or removed). This was particularly evident in the reviews which were conducted before the current recommenda-tions on terminology/technique on selective caries removal (consensuses) were published (Schwendicke et al. 2016; Machiulskiene et al. 2020; Splieth et al. 2020a; Santamaría et al. 2020). However, the findings of the current umbrella review showed that particularly in the treatment of deep carious lesions in primary teeth, the use of selective caries removal was beneficial to reduce the risk of pulp expo-sure. A SR and meta-analysis (Schwendicke et al. 2013) which was not included in present review due to pooled data reporting of primary and permanent teeth has com-pared selective caries removal (one-step) and stepwise caries removal with non-selective caries removal to hard dentine showed lower risk of pulpal exposure and pulpal symptoms for both management techniques. It is fair to say though the emergence of novel restorative technique with no caries removal such as the HT meant that there is currently less applications for selective caries removal in primary teeth.

With regards to ART, from the 8 SRs included, there was wide variability in the number of included studies ranging from 3 up to 15, with most SRs reporting high risk of bias in the included primary papers. Only two SRs reported a low risk of bias even though the included papers overlapped (Dorri et al. 2017; Tedesco et al. 2017). ART with HVGIC showed to be an adequate management option for treating single-surface carious lesions in pri-mary teeth. However, when ART was used in multi-surface carious lesions, the technique had less success rate with higher mean annual failure rate. It is worth noting that the quality of evidence from these SRs was low and hence the current umbrella review was not able to draw conclusions.

Unlike 38% SDF, ART was compared to conventional restorations in the majority of the reviews. This could be explained by the fact that ART has been considered an alternative treatment option to conventional restoration for carious primary teeth for a long period of time.

Similarly to our findings, a recent systematic review (Santamaría et al. 2020) (not included in the present umbrella review due to pooled data reporting RCTs and SRs) concluded that less invasive caries approaches involving selective or no caries removal and SDF appli-cation seem advantageous in comparison with complete


1 3

caries removal for patients presenting with vital, symp-tomless, carious dentine lesions in primary teeth.

This umbrella review is not without limitations. Data on different treatment outcomes were reported mainly based on the clinical findings of the included SRs with very lim-ited data were reported from post-operative radiographs. This might have under estimated the rate of the minor and major failures reported on these treatment techniques.

Conclusion and recommendation

The results of the current umbrella review confirm that despite the heterogeneity of the included SRs and primary studies, MID techniques appear to be effective in arrest-ing the progress of dentinal caries in primary teeth when compared to no treatment and conventional restorations. There is some evidence of improved patient reported out-comes with such techniques, however, further research is required in this area to inform guideline development and to ensure treatment recommendations are based on both clinical outcomes but more importantly child expe-rience and acceptance. There is a clear need to increase the emphasis on utilising MID techniques in managing dentinal caries lesions in primary teeth as a mainstream option rather than a compromise option in circumstances where the conventional approach is prohibited due to cost or cooperation.

Supplementary Information The online version contains supplemen-tary material available at https:// doi. org/ 10. 1007/ s40368- 021- 00675-6.

Funding This umbrella review was funded by the European Academy of Paediatric Dentistry.

Declarations

Conflict of interest The authors declare that they have no conflict of interest.

Ethical approval The present umbrella review did not require ethical approval.

Open Access This article is licensed under a Creative Commons Attri-bution 4.0 International License, which permits use, sharing, adapta-tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.

References

BaniHani A, Duggal M, Toumba J, et al. Outcomes of the conventional and biological treatment approaches for the management of car-ies in the primary dentition. Int J Paediatr Dent. 2018;28:12–22. https:// doi. org/ 10. 1111/ ipd. 12314.

BaniHani A, Deery C, Toumba J, et al. Effectiveness, costs and patient acceptance of a conventional and a biological treatment approach for carious primary teeth in children. Caries Res. 2019;53(1):65–75. https:// doi. org/ 10. 1159/ 00048 7201.

Bjorndal L. Stepwise excavation. Monogr Oral Sci. 2018;27:68–81. https:// doi. org/ 10. 1159/ 00048 7834.

Borges BCD, De Souza Bezerra Araújo RF, Dantas RF, et al. Effi-cacy of a non-drilling approach to manage non-cavitated dentin occlusal caries in primary molars: a 12-month randomized con-trolled clinical trial. Int J Paediatr Dent. 2012x;22:44–51. https:// doi. org/ 10. 1111/j. 1365- 263X. 2011. 01156.

Chibinski AC, Wambier LM, Feltrin J, et al. Silver diamine fluoride has efficacy in controlling caries progression in primary teeth: a sys-tematic review and meta-analysis. Caries Res. 2017;51:527–41. https:// doi. org/ 10. 1159/ 00047 8668.

Contreras V, Toro MJ, Elias-Boneta AR, et al. Effectiveness of silver diamine fluoride in caries prevention and arrest: a systematic lit-erature review. Gen Dent. 2017;65:22–9.

Crystal YO, Janal MN, Hamilton DS, et al. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc. 2017;148:510–8. https:// doi. org/ 10. 1016/j. adaj. 2017. 03. 013.

de Amorim RG, Frencken JE, Raggio DP, et al. Survival percentages of atraumatic restorative treatment (ART) restorations and sealants in posterior teeth: an updated systematic review and meta-analysis. Clin Oral Investig. 2018;22:2703–25. https:// doi. org/ 10. 1007/ s00784- 018- 2625-5.

Dorri M, Dunne SM, Walsh T, et al. Micro-invasive interventions for managing proximal dental decay in primary and permanent teeth. Cochrane Database Syst Rev. 2015x. https:// doi. org/ 10. 1002/ 14651 858. CD010 431.

Dorri M, Martinez-Zapata MJ, Walsh T, et al. Atraumatic restor-ative treatment versus conventional restorative treatment for managing dental caries. Cochrane Database Syst Rev. 2017;12:CD008072. https:// doi. org/ 10. 1002/ 14651 858. CD008 072.

Duangthip D, Jiang M, Chu CH, et al. Non-surgical treatment of dentin caries in preschool children–systematic review. BMC Oral Health. 2015;15:44. https:// doi. org/ 10. 1186/ s12903- 015- 0033-7.

Duangthip D, Jiang M, Chu CH, et al. Restorative approaches to treat dentin caries in preschool children: systematic review. Eur J Pae-diatr Dent. 2016;17:113–21.

Duangthip D, Chen KJ, Gao SS, et al. Managing early childhood car-ies with atraumatic restorative treatment and topical silver and fluoride agents. Int J Environ Res Public Health. 2017x. https:// doi. org/ 10. 3390/ ijerp h1410 1204.

El-Yousfi S, Innes NPT, Holmes RD, et al. Children and parents’ per-spectives on the acceptability of three management strategies for dental caries in primary teeth within the “filling children’s teeth: indicated or not” (FiCTION) randomised controlled trial-a quali-tative study. BMC Oral Health. 2020;20:69. https:// doi. org/ 10. 1186/ s12903- 020- 1060-6.

Ericson D, Kidd E, McComb D, et al. Minimally invasive dentistry–concepts and techniques in cariology. Oral Health Prev Dent. 2003;1:59–72.

Frencken JE, Peters MC, Manton DJ, et al. Minimal intervention den-tistry for managing dental caries-a review: report of a FDI task group. Int Dent J. 2012;62:223–43. https:// doi. org/ 10. 1111/ idj. 12007.

https://doi.org/10.1007/s40368-021-00675-6

http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1111/ipd.12314

https://doi.org/10.1159/000487201

https://doi.org/10.1159/000487834

https://doi.org/10.1111/j.1365-263X.2011.01156

https://doi.org/10.1111/j.1365-263X.2011.01156

https://doi.org/10.1159/000478668

https://doi.org/10.1016/j.adaj.2017.03.013

https://doi.org/10.1007/s00784-018-2625-5

https://doi.org/10.1007/s00784-018-2625-5

https://doi.org/10.1002/14651858.CD010431

https://doi.org/10.1002/14651858.CD010431

https://doi.org/10.1002/14651858.CD008072

https://doi.org/10.1002/14651858.CD008072

https://doi.org/10.1186/s12903-015-0033-7

https://doi.org/10.3390/ijerph14101204

https://doi.org/10.3390/ijerph14101204

https://doi.org/10.1186/s12903-020-1060-6

https://doi.org/10.1186/s12903-020-1060-6

https://doi.org/10.1111/idj.12007

https://doi.org/10.1111/idj.12007


1 3

Gao SS, Zhao IS, Hiraishi N, et al. Clinical trials of silver diamine fluoride in arresting caries among children: a systematic review. JDR Clin Transl Res. 2016;1:201–10. https:// doi. org/ 10. 1177/ 23800 84416 661474.

Gruythuysen RJM, van Strijp AJPG, van Palestein Helderman WH, et al. Non-restorative treatment of cavities in temporary den-tition: effective and child-friendly. Ned Tijdschr Geneeskd. 2011;155:A3489.

Hesse D, Bonifácio CC, Mendes FM, et al. Sealing versus partial caries removal in primary molars: a randomized clinical trial. BMC Oral Health. 2014;14:58.

Higgins J, Thomas J, Chandler J, et al. Cochrane handbook for sys-tematic reviews of interventions version 6.1 [Internet]. Available from: www. train ing. cochr ane. org/ handb ook. 2020

Honkala E, Behbehani J, Ibricevic H, et al. The atraumatic restorative treatment (ART) approach to restoring primary teeth in a standard dental clinic. Int J Paediatr Dent. 2003;13:172–9. https:// doi. org/ 10. 1046/j. 1365- 263x. 2003. 00455.

Innes NP, Evans DJ, Stirrups DR. The hall technique; a randomized controlled clinical trial of a novel method of managing cari-ous primary molars in general dental practice: acceptability of the technique and outcomes at 23 months. BMC Oral Health. 2007;7:1–21. https:// doi. org/ 10. 1186/ 1472- 6831-7- 18.

Innes NPT, Ricketts D, Chong LY, et al. Preformed crowns for decayed primary molar teeth. Cochrane Database Syst Rev. 2015x. https:// doi. org/ 10. 1002/ 14651 858. CD005 512.

Innes NPT, Evans DJP, Bonifacio CC, et al. The hall technique 10 years on: questions and answers. Br Dent J. 2017;222:478–83. https:// doi. org/ 10. 1038/ sj. bdj. 2017. 273.

Jabin Z, Vishnupriya V, Agarwal N, et al. Effect of 38% silver diamine fluoride on control of dental caries in primary dentition: a system-atic review. J Fam Med Prim Care. 2020;9:1302–7. https:// doi. org/ 10. 4103/ jfmpc. jfmpc_ 1017_ 19.

Kidd E. The implications of the new paradigm of dental caries. J Dent. 2011;39:3–8. https:// doi. org/ 10. 1016/j. jdent. 2011. 11. 004.

Kidd E, Fejerskov O. Changing concepts in cariology: forty years on. Dent Update. 2013;40(277–278):280–6. https:// doi. org/ 10. 12968/ denu. 2013. 40.4. 277.

Machiulskiene V, Campus G, Carvalho J, et al. Terminology of dental caries and dental caries management: consensus report of a work-shop organized by ORCA and cariology research group of IADR. Caries Res. 2020;54:7–14. https:// doi. org/ 10. 1159/ 00050 3309.

Mickenautsch S, Yengopal V. Failure rate of high-viscosity GIC based ART compared with that of conventional amalgam restorations–evidence from an update of a systematic review. SADJ J South African Dent Assoc. 2012;67:329–31.

Ortiz-Ruiz AJ, Pérez-Guzmán N, Rubio-Aparicio M, et al. Success rate of proximal tooth-coloured direct restorations in primary teeth at 24 months: a meta-analysis. Sci Rep. 2020;10:6409. https:// doi. org/ 10. 1038/ s41598- 020- 63497-4.

Paris S, Bitter K, Krois J, et al. Seven-year-efficacy of proximal caries infiltration-randomized clinical trial. J Dent. 2020;93: 103277. https:// doi. org/ 10. 1016/j. jdent. 2020. 103277.

Raggio DP, Hesse D, Lenzi TL, et al. Is Atraumatic restorative treat-ment an option for restoring occlusoproximal caries lesions in primary teeth? A systematic review and meta-analysis. Int J Pae-diatr Dent. 2013;23:435–43. https:// doi. org/ 10. 1111/ ipd. 12013.

Richards D. The effectiveness of silver diamine fluoride in arresting caries. Evid Based Dent. 2017;18:70. https:// doi. org/ 10. 1038/ sj. ebd. 64012 50.

Ricketts D, Lamont T, Innes NPT, et al. Operative caries manage-ment in adults and children. Cochrane Database Syst Rev. 2013x. https:// doi. org/ 10. 1002/ 14651 858. CD003 808.

Santamaria R, Innes N. Sealing carious tissue in primary teeth using crowns: the hall technique. Monogr Oral Sci. 2018;27:113–23. https:// doi. org/ 10. 1159/ 00048 7835.

Santamaria RM, Innes NPT, Machiulskiene V, et al. Alternative caries management options for primary molars: 2.5-year outcomes of a randomised clinical trial. Caries Res. 2018x;51:605–14. https:// doi. org/ 10. 1159/ 00047 7855.

Santamaría RM, Abudrya MH, Gül G, et al. How to intervene in the caries process: dentin caries in primary teeth. Caries Res. 2020x. https:// doi. org/ 10. 1159/ 00050 8899.

Schwendicke F, Dorfer CE, Paris S. Incomplete caries removal: a sys-tematic review and meta-analysis. J Dent Res. 2013;92:306–14. https:// doi. org/ 10. 1177/ 00220 34513 477425.

Schwendicke F, Frencken JE, Bjorndal L, et al. Managing carious lesions: consensus recommendations on carious tissue removal. Adv Dent Res. 2016;28:58–67. https:// doi. org/ 10. 1177/ 00220 34516 639271.

Schwendicke F, Splieth C, Breschi L, et al. When to intervene in the caries process? An expert delphi consensus statement. Clin Oral Investig. 2019;23(10):3691–703. https:// doi. org/ 10. 1007/ s00784- 019- 03058-w.

Splieth CH, Banerjee A, Bottenberg P, et al. How to intervene in the caries process in children: a joint ORCA and EFCD expert delphi consensus statement. Caries Res. 2020a. https:// doi. org/ 10. 1159/ 00050 7692.

Splieth CH, Kanzow P, Wiegand A, et al. How to intervene in the caries process: proximal caries in adolescents and adults-a systematic review and meta-analysis. Clin Oral Investig. 2020b;24:1623–36. https:// doi. org/ 10. 1007/ s00784- 020- 03201-y.

Tedesco TK, Calvo AFB, Lenzi TL, et al. ART is an alternative for restoring occlusoproximal cavities in primary teeth-evidence from an updated systematic review and meta-analysis. Int J Paediatr Dent. 2017;27:201–9. https:// doi. org/ 10. 1111/ ipd. 12252.

Tedesco TK, Gimenez T, Floriano I, et al. Scientific evidence for the management of dentin caries lesions in pediatric dentistry: a sys-tematic review and network meta-analysis. PLoS ONE. 2018x. https:// doi. org/ 10. 1371/ journ al. pone. 02062 96.

Tolba ZO, Hamza HS, Moheb DM, et al. Effectiveness of two con-centrations 12% versus 38% of silver diamine fluoride in arrest-ing cavitated dentin caries among children: a systematic review. Egypt Pediatr Assoc Gaz. 2019;67:1. https:// doi. org/ 10. 1186/ s43054- 019- 0001-y.

Trieu A, Mohamed A, Lynch E. Silver diamine fluoride versus sodium fluoride for arresting dentine caries in children: a systematic review and meta-analysis. Sci Rep. 2019;9:2115. https:// doi. org/ 10. 1038/ s41598- 019- 38569-9.

Van’t-Hof MA, Frencken JE, van Palenstein Helderman WH, et al. The atraumatic restorative treatment (ART) approach for manag-ing dental caries: a meta-analysis. Int Dent J. 2006x;56:345–51. https:// doi. org/ 10. 1111/j. 1875- 595x.

Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

https://doi.org/10.1177/2380084416661474

https://doi.org/10.1177/2380084416661474

http://www.training.cochrane.org/handbook

https://doi.org/10.1046/j.1365-263x.2003.00455

https://doi.org/10.1046/j.1365-263x.2003.00455

https://doi.org/10.1186/1472-6831-7-18

https://doi.org/10.1002/14651858.CD005512

https://doi.org/10.1002/14651858.CD005512

https://doi.org/10.1038/sj.bdj.2017.273

https://doi.org/10.1038/sj.bdj.2017.273

https://doi.org/10.4103/jfmpc.jfmpc_1017_19

https://doi.org/10.4103/jfmpc.jfmpc_1017_19

https://doi.org/10.1016/j.jdent.2011.11.004

https://doi.org/10.12968/denu.2013.40.4.277

https://doi.org/10.12968/denu.2013.40.4.277

https://doi.org/10.1159/000503309

https://doi.org/10.1038/s41598-020-63497-4

https://doi.org/10.1038/s41598-020-63497-4

https://doi.org/10.1016/j.jdent.2020.103277


https://doi.org/10.1038/sj.ebd.6401250

https://doi.org/10.1038/sj.ebd.6401250

https://doi.org/10.1002/14651858.CD003808

https://doi.org/10.1159/000487835

https://doi.org/10.1159/000477855

https://doi.org/10.1159/000477855

https://doi.org/10.1159/000508899

https://doi.org/10.1177/0022034513477425

https://doi.org/10.1177/0022034516639271

https://doi.org/10.1177/0022034516639271

https://doi.org/10.1007/s00784-019-03058-w

https://doi.org/10.1007/s00784-019-03058-w

https://doi.org/10.1159/000507692

https://doi.org/10.1159/000507692

https://doi.org/10.1007/s00784-020-03201-y


https://doi.org/10.1371/journal.pone.0206296

https://doi.org/10.1186/s43054-019-0001-y

https://doi.org/10.1186/s43054-019-0001-y

https://doi.org/10.1038/s41598-019-38569-9

https://doi.org/10.1038/s41598-019-38569-9

https://doi.org/10.1111/j.1875-595x


1 3

Authors and Affiliations

A. BaniHani1 · R. M. Santamaría2 · S. Hu3 · M. Maden4 · S. Albadri5

* S. Albadri [email protected]

1 Department of Paediatric Dentistry, School of Dentistry, University of Leeds, Leeds, UK

2 Department of Preventive and Paediatric Dentistry, University of Greifswald, Greifswald, Germany

3 Faculty of Dentistry, National University of Singapore, Singapore, Singapore

4 Liverpool Reviews & Implementation Group, University of Liverpool, Liverpool, UK

5 School of Dentistry, University of Liverpool, Pembroke place, Liverpool L3 5PS, UK

http://orcid.org/0000-0002-7733-272X

minimal intervention dentistry for managing carious

Documents